Every year, NHS England conducts pre-winter “stress-tests”, scenario planning exercises often likened to war-games, to assess how well systems are prepared for seasonal surges. Yet, too often, these exercises remain paper exercises rather than operational reality. As winter 2025 looms, with urgent care demand set to collide with elective backlogs and workforce fragility, the challenge for leaders is to translate national stress-tests into ward-level resilience. This blog explores what NHSE’s winter checks mean, the gaps they expose, and how Integrated Care Systems (ICSs) and providers can act decisively.

 

 

What the Winter Stress-Tests Show

NHSE’s 2025/26 winter assurance process has focused on:

• Respiratory surge capacity (RSV, flu, COVID variants)
• Frailty front-doors and SDEC (Same Day Emergency Care)
• Bed occupancy thresholds
• Staffing resilience and rostering plans
• Discharge and social care coordination

The findings are stark: most systems are not confident they can sustain elective activity while managing urgent care peaks. Bed occupancy remains above 90% in many regions, leaving little buffer.

From Scenario to Reality: Lessons from the Frontline

Stress-tests highlight risks, but the reality is felt at ward level:

• Corridor Care Normalisation: Trusts are still reporting 12-hour A&E waits and patients on trolleys, even before winter peaks.
• Makeshift Expansions: As seen in Kent, where a café was converted into an A&E ward, contingency often means repurposing inappropriate spaces.
• Staffing Shortfalls: Rostering models look robust on paper but collapse when sickness absence spikes, leaving significant shifts unfilled.

Without bridging this gap between planning and lived reality, stress-tests become symbolic rather than transformative.

Workforce: The Unstable Foundation

Winter planning cannot succeed on a depleted workforce:

• The NHS Staff Survey 2024 showed over 40% of staff reported feeling burned out.
• Attrition is accelerating across the NHS workforce, from nurses and paramedics to GPs and hospital doctors. Rising early retirements, reduced hours, and moves into private or overseas work are depleting capacity faster than training pipelines can replace it.
• Agency demand has been artificially suppressed to cut costs and force staff into banks, yet many bank shifts are now as expensive, or more costly, than agency or substantive roles. The result is fewer options to plug urgent gaps, and a workforce system weakened at the very moment resilience is most needed.

Any stress-test that assumes stable staffing levels is fundamentally flawed. Workforce fragility must be the first risk considered, not the last.

What ICSs and Providers Can Do Now

1. Translate Scenarios into Ward-Level Protocols

Stress-tests must be followed by clear ward-level actions: escalation triggers, decision trees, and responsibilities assigned. Staff on the ground must know what to do when thresholds are breached.

2. Protect Elective Activity with Firm Escalation Protocols

Systems should agree in advance which elective lists will be protected, even under pressure. Default cancellation worsens backlogs and morale.

3. Strengthen SDEC and Frailty Pathways

Well-functioning SDEC units reduce bed pressures significantly. Investment in staffing and logistics here pays off quickly.

4. Joint Command Centres

ICSs should run real-time operational command centres linking acute, community, and social care partners, with authority to act fast.

5. Stress-Test the Workforce

Plans must go beyond financial spreadsheets. They should reflect the lessons from NHS England’s Exercise Aegis, stress-testing sickness absence, workforce redeployment, and service continuity, and be subject to robust Quality Impact Assessments (QIAs) to ensure the workforce is fit for purpose, demand is met, and care quality is not compromised.

The Social Care Bottleneck

No stress-test can ignore discharge. In many Trusts, hundreds of patients are medically fit but unable to leave due to a lack of social care capacity. This is not just a winter bottleneck, it is the single biggest hinge between NHS flow and social care sustainability. Yet every year, the same cycle repeats: short-term spot purchasing of care packages and crisis talks with councils. Leaders must break this cycle. ICSs should put in place year-round block contracts with domiciliary care providers, build integrated discharge hubs with real-time authority, and use joint NHS–local authority command centres to coordinate flow. Unless discharge is treated as a strategic function, not a seasonal fire-fight, winter escalation will remain inevitable.

Political Responsibility

While NHSE runs its stress-tests, the Labour government under Wes Streeting continues to restrict the very resources those plans depend on. Agency demand has been artificially suppressed to cut costs and force staff into banks, yet many bank shifts are now as costly, or more costly, than agency or substantive roles. The result is less flexibility, weaker resilience, and leaders left with scenarios on paper but insufficient tools in practice. Temporary staffing has always been the NHS’s shock absorber and safety net; undermining it not only weakens today’s resilience but risks long-term damage to trust, morale, and the sustainability of the workforce itself.

Final Word – Altin Biba, MBA, AMBA

Stress-tests only have value if they drive action, not reassurance. Winter 2025 will expose the gap between scenarios and reality: wards without staff, beds without flow, and patients without timely care. Leaders must turn plans into lived resilience, protecting elective activity, strengthening frailty pathways, and confronting the truth about workforce fragility. Temporary staffing has always been the NHS’s shock absorber and safety net, yet it is being weakened by short-term politics. Government must stop confusing paper exercises with preparedness. Winter is coming, and patients will not be protected by scenarios. Only genuine investment in people and capacity can change the outcome.

References

1. NHS England. Winter Assurance Guidance 2025/26.
2. NHS Providers. Winter Readiness Briefing, 2025.
3. The Telegraph. William Harvey Hospital Uses Café as Makeshift A&E Ward. September 2025.
4. NHS Staff Survey 2024. Workforce Engagement and Burnout Findings.
5. King’s Fund. Winter Pressures and NHS Preparedness.
6. HSJ. Same Day Emergency Care and Frailty Pathways – Impact on Bed Flow.